Qualified Plan Intake
PLAN TYPE
*
Please Select One
Option 1
Option 2
Option 3
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Plan #
# of Participants
*
1. Entity Company Name
Notes
Entity Taxed As
C Corp
S Corp
Non Profit
Partnership
Partnership
LLP
Sole Proprietorship
Union
Government Agency
Other (please list below)
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Entity Information
4. Entity Fiscal Year End (If not 12/31)
5. Entity State of Organization
6. Entity TIN/EIN
7. Entity Legal Address
8. Entity Business Phone #
9. Entity Mailing Address
10. Entity Business Email Address
Notes
Plan Sponsor (Company) Contact:
Full Name of Contact
Plan Sponsor Contact is Trustee
Correct
Plan Sponsor Contact is not Trustee
Correct
Name
Title
Phone
Fax
Email
*
Trustee Information
Notes
11. Primary Trustee of Plan: (Leave empty is same as above or)
12. Secondary Trustee of Plan (if one exists)
13. Is Secondary Trustee the Spouse of the Primary Trustee?
Yes
Yes
No
No
Notes
Application for Plan EIN
Responsible Party Name
Responsible Party DOB
Responsible Party Address
Responsbile Party SSN
Notes
Responsbile Party Phone
Responsible Party Email
Electronic Signature (Binding)
Clear
Electronic Signature (Binding)
Date
SUBMIT